REACH MUSC: A Telemedicine Facilitated Network for Stroke: Initial Operational Experience

REACH Medical University of South Carolina (MUSC) provides stroke consults via the internet in South Carolina. From May 2008 to April 2011 231 patients were treated with intravenous (IV) thrombolysis and 369 were transferred to MUSC including 42 for intra-arterial revascularization [with or without IV tissue plasminogen activator (tPA)]. Medical outcomes and hemorrhage rates, reported elsewhere, were good (Lazaridis et al., 2011). Here we report operational features of REACH MUSC which covers 15 sites with 2,482 beds and 471,875 Emergency Department (ED) visits per year. Eight Academic Faculty from MUSC worked with 165 different physicians and 325 different nurses in the conduct of 1085 consults. For the 231 who received tPA, time milestones (in minutes) were: Onset to Door: 62 (mean), 50 (median); Door to REACH Consult: 43 and 33, Consult Request to Consult Start: was 9 and 7, Consult Start to tPA Decision: 31 and 25; Decision to Infusion: 20 and 14, and total Door to Needle: 98 and 87. The comparable times for the 854 not receiving tPA were: Onset to Door: 140 and 75; Door to REACH Consult: 61 and 41; Consult Request to Consult Start: 9 and 7, Consult Start to tPA Decision: 27 and 23. While the consultants respond to consult requests in <10, there is a long delay between arrival and Consult request. Tracking of operations indicates if we target shortening Door to Call time and time from tPA decision to start of drug infusion we may be able to improve Door to Needle times to target of <60. The large number of individuals involved in the care of these patients, most of whom had no training in REACH usage, will require novel approaches to staff education in ED based operations where turnover is high. Despite these challenges, this robust system delivered tPA safely and in a high fraction of patients evaluated using the REACH MUSC system

Protracted Respiratory Failure in a Case of Global Spinal Syringomyelia and Chiari Malformation Following Administration of Diazepam: Illustrative Case

BACKGROUND: Syringomyelia is defined as dilation of the spinal cord\u27s central canal and is often precipitated by skull base herniation disorders. Although respiratory failure (RF) can be associated with skull base abnormalities due to brainstem compression, most cases occur in pediatric patients and quickly resolve. The authors report the case of an adult patient with global spinal syringomyelia and Chiari malformation who developed refractory RF after routine administration of diazepam. OBSERVATIONS: A 31-year-old female presented with malnutrition, a 1-month history of right-sided weakness, and normal respiratory dynamics. After administration of diazepam prior to magnetic resonance imaging (MRI), she suddenly developed hypercapnic RF followed MRI and required intubation. MRI disclosed a Chiari malformation type I and syrinx extending from C1 to the conus medullaris. After decompressive surgery, her respiratory function progressively returned to baseline status, although 22 months after initial benzodiazepine administration, the patient continues to require nocturnal ventilation. LESSONS: Administration of central nervous system depressants should be closely monitored in patients with extensive syrinx formation given the potential to exacerbate diminished central respiratory drive. Early identification of syrinx in the context of Chiari malformation and hemiplegia should prompt clinical suspicion of underlying respiratory compromise and early involvement of intensive care consultants

Caso clínico de la unidad de medicina interna hipertensión arterial de origen renovascular

Hombre de 28 años, natural y procedente de Bogotá, consulto por cefalea progresiva fronta-occipital de treinta horas de evolución, acompañada de vomito en dos oportunidades y de trastorno de la conciencia, con relajación del esfínter vesical. La esposa informo episodio similar un mes ames, cuando fue hospitalizado, encontrándose HTA y hemorragia subaracnoidea. Salió contratamiento triconjugado (captopril, nifedipina, propanolol), el cual suspendió ocho días antes del ingreso

Journal of Engineering Notebooks. N.1

La aparición del primer número de Cuadernos de Ingeniería, es un punto de inflexión en el desarrollo ordenado de la actividad investigativa de la UNAB y específicamente en la Escuela de Ciencias Naturales e Ingeniería.Presentación. - 7 Algortimo estocástico para solución de un problema de control. - 11 Biosorción de metales pesados mediante el uso de biomasa microbiana. - 21 Caracterización química del bagazo de caña, de la yuca raíz sin cáscara y del residuo fibroso de la palma africana como fuentes potenciales en la producción de etanol carburante por vía biotecnológica. - 33 Efecto doppler de una fuente sonora con movimiento armónico simple. - 55 Modelos matemáticos para procesos de mercado. - 67The appearance of the first issue of Engineering Notebooks is a turning point in the orderly development of the research activity at UNAB and specifically at the School of Natural Sciences and Engineering

Rising statin use and effect on ischemic stroke outcome

BACKGROUND: Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) have neuroprotective effects in experimental stroke models and are commonly prescribed in clinical practice. The aim of this study was to determine if patients taking statins before hospital admission for stroke had an improved clinical outcome. METHODS: This was an observational study of 436 patients admitted to the National Institutes of Health Suburban Hospital Stroke Program between July 2000 and December 2002. Self-reported risk factors for stroke were obtained on admission. Stroke severity was determined by the admission National Institutes of Health Stroke Scale score. Good outcome was defined as a Rankin score < 2 at discharge. Statistical analyses used univariate and multivariate logistic regression models. RESULTS: There were 436 patients with a final diagnosis of ischemic stroke; statin data were available for 433 of them. A total of 95/433 (22%) of patients were taking a statin when they were admitted, rising from 16% in 2000 to 26% in 2002. Fifty-one percent of patients taking statins had a good outcome compared to 38% of patients not taking statins (p = 0.03). After adjustment for confounding factors, statin pretreatment was associated with a 2.9 odds (95% CI: 1.2–6.7) of a good outcome at the time of hospital discharge. CONCLUSIONS: The proportion of patients taking statins when they are admitted with stroke is rising rapidly. Statin pretreatment was significantly associated with an improved functional outcome at discharge. This finding could support the early initiation of statin therapy after stroke

Military Soft Skills Applicable to the ICU

OBJECTIVES:. To describe how soft skills acquired during military service can be applied to the practice of critical care medicine. DATA SOURCES:. A systematic search was performed in PubMed. STUDY SELECTION:. We selected all studies that addressed soft skills in medicine. DATA EXTRACTION:. Information present in published articles was analyzed by the authors and incorporated in the article if relevant to the practice of critical care medicine. DATA SYNTHESIS:. Integrative review of 15 articles combined with the authors' clinical experience practicing military medicine in country and overseas while also practicing academic intensive care medicine. CONCLUSIONS:. Soft skills used in the military have potential applications to modern intensive care medicine. Teaching soft skills in parallel with the technical aspects of intensive care medicine should be an integral part of critical care fellowships

Significance of parenchymal brain damage in patients with critical illness

To determine the prevalence, type, and significance of brain damage in critically ill patients with a primary non-neurological diagnosis developing acute brain dysfunction.; This retrospective cohort study was performed at the Johns Hopkins University School of Medicine, an academic tertiary care hospital. Medical records were reviewed of 479 consecutive ICU patients who underwent brain magnetic resonance imaging (MRI) over a 2-year period. Patients were selected for analysis if MRI was obtained to evaluate an acute onset of brain dysfunction (altered mental status, seizures, and/or focal neurological deficit). Subjects with a history of a central nervous system disorder were excluded. The principal clinical endpoint was Glasgow Outcome Scale (GOS) assessed at discharge. MRI-defined brain abnormalities were classified according to type and location. Factors associated with MRI-defined abnormalities were assessed in uni- and multivariable models.; 146 patients met inclusion criteria (mean age 54 ± 7 years). Brain damage was detected in 130 patients (89 %). The most prevalent lesions were white matter hyperintensities (104/146, 71 %) and acute cerebral infarcts (59/146, 40 %). In a multivariable model, lesions on brain MRI were independently associated with unfavorable outcome (GOS1-3 in 71 % of patients with lesions vs. 44 % in those without, p = 0.007). No adverse events occurred in relation to transport and MRI scanning.; In critically ill patients without known neurological disease who have acute brain dysfunction, MRI reveals an unexpectedly high burden of underlying brain damage, which is associated with unfavorable outcome. The results indicate that brain damage could be an important and under-recognized factor contributing to critical illness brain dysfunction